The Best Laid Plans: A “Trial by Fire”

From around 2009 to 2016, I worked very closely with a USA-trained surgeon, Dr. Brian Camazine of Earthwide Surgical Foundation, who visits Nigerian Christian Hospital in Aba, Nigeria for one month every quarter. He performs between 200 to 300 surgeries, which produce 40 to 60 surgical pathology specimens each visit. Dr. Camazine has invested time, energy, and money into training local Nigerians in surgical skills, acquiring surgical and medical supplies to support his patient population, and following up all of his patients with Skype clinics after he returns.

My role in Dr. Camazine’s activities was to receive the surgical pathology samples, process them, and return results for him as quickly as possible. When Dr. Camazine contacted me, there was no pathology laboratory at NCH. Dr. Camazine uses a heavily subsidized model for all of the services provided at NCH such that a patient may pay ~$200 for a surgery (complete care including pathology) that would have cost them $2,000 to $4000 elsewhere in Nigeria. My hospital at the time had an ongoing project of a similar fashion with several sites in Africa but the costs of that program were growing. Dr. Camazine agreed to pay a fee of $25 per sample to my hospital to offset the technical costs of our laboratory processing the samples, and I provided all diagnostic results pro bono. Dr. Camazine was only charging patients $20 per case for pathology; thus, he subsidized the service further.

I had many long and difficult discussions with Dr. Camazine about this program and how we needed to focus on a sustainable solution that did not involve transport to the US for processing for many reasons including (but not limited to): a) danger and difficulty with sending tissue, b) long turnaround time because of shipping delays, c) chain of custody and requisition challenges, and d) capacity building in pathology. We kept at it with this long-term plan in mind but, as I departed my hospital to join ASCP in 2016, a drastic decision had to be made because I would no longer be able to shepherd this service. Dr. Camazine reached out locally to Nigerian laboratories and was fortunate to meet Dr. Chidi Onwuka from the Department of Histopathology at the University of Uyo Teaching Hospital. Brian and Chidi came to a feasible financial arrangement and, with the closeness of the laboratory, Chidi can return results to Brian in about 1 week (Meet Chidi and read Brian’s Blog here). This was a great success for Brian and Chidi because it represented moving from a non-sustainable, bridging program (i.e., what I had set up with Brian) to a permanent solution with the local laboratory. For over two years, Chidi has provided high quality service with quick turnaround time and massively improved the patient care journey for NCH patients.

On June 27th, 2018, however, that complete pathology solution came to a screeching halt when a fire swept through the laboratory and destroyed all of the equipment and reagents. The laboratory in question had just been completely updated with 40 Million Naira (~$115,000 USD) worth of equipment and upgrades, but it was all lost. Dr. Chidi reached out to Brian, myself, and many others with an urgent request to help him get a replacement laboratory up and running. After so much success, it was heartbreaking to hear such a loss had occurred.

The ASCP Partners for Cancer Diagnosis and Treatment in Africa Initiative was launched in 2015 with a goal of bringing 100% access to cancer diagnostics services to all patients. Although the population of patients Brian cares for and Chidi diagnoses are within Africa and within the scope of the Partners Initiative, at the time of the fire, there were at least 10 laboratory projects (including equipment, training, IHC, telepathology, etc.) in process through the Partners project. We were seemingly “at capacity” to help. What could we do? Although we have ASCP member volunteers that donate equipment, we have a waiting list of labs wanting to receive the equipment. Although Brian and Chidi are my colleagues and friends, the distribution of global health resources, assistance, and capacity should always be done with equity. As part of the Partners Initiative, ASCP Center for Global Health acquires equipment (typically through donation which means donor requirements of the local countries) and covers shipping costs to move the equipment to the recipient sites but we had not yet formalized this process. But, for Chidi, I simply didn’t have the equipment available to send.

Then, I received a WhatsApp message from Chidi on August 3rd with a small bit of good news. He had located a microtome in the USA that he could purchase; however, he did not have sufficient funds to ship the equipment. Now, finally, ASCP could help him! But it was not quite that easy!

ASCP staff member Dr. Debby Basu got the microtome in the USA to Chidi in Nigeria. This was not an easy task. Debby faced two major challenges for organizing Chidi’s shipment. First, she had to establish key templates and tools necessary to facilitate donation. Although we have several sets of donated equipment that are to be shipped from ASCP to other sites, Chidi’s microtome was the first actual piece of equipment that would go with our new shipping agent. As this was our first shipment with Bollore, she first had to work with Bollore to determine what documentation ASCP was responsible for providing. She then developed the in-house documents, templates and tools needed to facilitate shipment using Bollore’s services (e.g. commercial invoice, packing list, Shipper’s Letter of Instructions (SLI) Form (customs information), donor letters, etc.). She served as the liaison between the original vendor, recipient and shipper to make sure that donation and shipping documentation was consistent, and that information was clear and available to all parties. The second challenge was understanding the complex international shipping guidelines for exporting scientific instruments and goods on US side and importing donation on receiving end. To address this on the domestic side, she worked closely with the shipper directly to clarify domestic customs guidelines specific to the context of the items being shipped and ensure customs documentation was completed appropriately. On the Nigerian side, she connected Chidi to Bollore’s Nigeria-based shipping team to establish a local point of contact for him. She then coordinated with both the US-based and Nigeria-based shipping teams to clarify country-specific importation requirements and provide Chidi with necessary documentation to ensure smooth receipt of instrument. It had been ASCP’s intention to use Bollore for the donation program but Chidi’s emergency pushed our agenda forward and Debby was able to race into action to make the process go. Now, Chidi has his microtome (and is replacing his other equipment) and ASCP’s shipping donation program has its process finalized for the next series of donations.

ASCP is so grateful to all of our members and member volunteers who have made the Partners Initiative a functional and impactful global health program. We are careful in our assessments, planning, and development of implementation plans with each of our sites and their leadership. However, terrible things happen unexpectantly. We hope that ASCP can always be a light in the dark when all others have gone out.

-Dan Milner, MD, MSc, spent 10 years at Harvard where he taught pathology, microbiology, and infectious disease. He began working in Africa in 1997 as a medical student and has built an international reputation as an expert in cerebral malaria. In his current role as Chief Medical officer of ASCP, he leads all PEPFAR activities as well as the Partners for Cancer Diagnosis and Treatment in Africa Initiative.